Individual Case Formulation

Richard S. Hallam

• Publisher: Academic Press
• Year: 2013
• Print ISBN: 9780123982698
• eBook ISBN: 9780123982797
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Individual Case Formulation presents formulation as a process that can be taught systematically to trainee therapists. The book begins by discussing assorted theories of case formulation, and critiques their ability to be applied in real world situations. The individual case formulation approach is then defined and discussed as a way to integrate the best of what different theoretical orientations have to offer in conjunction with the expertise and clinical judgment of the therapist. The book proposes a systemic/functional framework that focuses on difficulties as defined by the client and emphasizes constructive solutions to problems rather than symptom reduction. Moving from theory to application, the book then guides therapists in how to conduct assessment interviews, how to reach a provisional formulation, how to test that formulation for accuracy and reformulate if necessary, how a therapist can make explicit what their clinical reasoning was in making the case formulation, and provides case examples and transcripts so readers will better grasp the concepts in action.Intended both for the starting or trainee therapist and the experienced clinician, Individual Case Formulation provides a practical guide for those looking to improve their case formulation skills.- Reviews, critiques and compares multiple theories on formulation- Identifies benefits of utilizing the individual case approach- Guides trainee therapists how to conduct assessment interviews and reach a provisional formulation- Presents a conceptual framework for developing and testing a formulation- Helps trainees make explicit their clinical reasoning- Field-tested for several decades- Provides case examples with annotated transcripts to illustrate the process of formulation

Chapter 1

Formulation—the Main Issues

The topic of case formulation immediately brings to the surface a number of simmering and unresolved issues in the field of psychotherapy. This chapter introduces the issues and outlines how this book will deal with them. A major paradox is the disparity between the high esteem in which case formulation is held and the lack of any serious attempt to investigate how it is conducted in practice. Of course, all of the many forms of psychotherapy make recommendations as to how a therapist should assess and formulate a client’s problem. However, formulation is so closely linked to a particular model of practice that the common features of the moment-to-moment process of formulation are rarely studied. One contentious issue concerns the role of diagnosis in formulation. Many psychotherapists, especially advocates of evidence-based practice, consider that formulation should include assigning a client’s difficulties to a type of psychological disorder, usually one specified by a psychiatric classification scheme. The rationale is that a diagnosis connects a client’s difficulties to a large evidence base of scientific knowledge about “psychopathology.”

The position I adopt in this book is that psychopathology does not constitute a science in its own right. I assert this on the grounds that the problems a client presents are rarely produced by dysfunctions of natural processes that differentiate “normal” from “disordered” people. Consequently, I will avoid terminology with a medical resonance such as “symptom,” “disorder,” “patient,” and “clinician” and substitute the terms “problem,” “difficulty,” “client,” and “practitioner.” However, this resort to non-medical language is not an anti-scientific stance. In fact, I will put forward formulation as a process that draws heavily on scientific knowledge, and maintain that the process of formulation can be compared to a form of scientific inquiry.

The terminology I adopt implies that psychotherapy is a form of problem solving rather than treatment of a psychological disorder. This is a fundamental difference of view and not one that is easily bridged. It is not a difference stemming from a belief that general psychological theory is not needed for case formulation. Rather, a problem is understood to exist at a higher level of analysis; it is a kind of obstacle or lack of something that prevents a client from satisfying their aims or, more simply, from living without distress. A problem occurs in a personal, social, and moral context, and so its causes need to be formulated at a level in which the meaning of someone’s life can be grasped. The term “problem” leaves open what framework of meaning is employed, although this book proposes a functional view (see Chapter 8). Narrative and textual approaches to case formulation are discussed in Chapter 6.

One implication of a problem-solving perspective is that reasoning in case formulation takes a hybrid form. Principles that derive from an understanding of natural processes and their technological application are relevant, but so, also, is the kind of reasoning that enters into anyone’s reflections on a moral dilemma or a choice in life. Not all psychotherapists would want to endorse a problem-solving terminology, but I suspect that most therapeutic tasks could be understood in this way. Even exploration and reflection come to an end when a client feels that he or she has explored enough or concludes that he or she is no longer learning anything useful. This process could be reframed as “clarifying a problem” or “making a decision about whether there really is a problem to be solved.” Thus, case formulation is not a morally neutral activity, nor need it be assumed that there is only one set of “real causes” of a problem. Presumably, construing a problem in different ways has different causal effects, some of which are intended to be beneficial. It is possible that one beneficial effect of solving a problem in a certain way is to disguise its “true causes” as seen from another perspective.

This book advances the claim that producing a good individual case formulation (ICF) is one of the key elements of therapeutic success. To put this differently, however much a general model of therapeutic change has been supported by evidence, it is its detailed translation for the individual that is of paramount importance. This places considerable responsibility on the therapist and her or his independent judgment. However, in the light of very little evidence concerning the merits of individually tailored therapy over standardized protocols, a case has to be made to justify it. The individual approach does not mean that every client will receive a different intervention. There is a body of knowledge that informs the analysis of problems that certainly does have implications for the selection of a method designed to solve them. Practice that is led by ICF is guided by an evidence base as well as by other forms of knowledge.

The significance I attach to independent judgment places the psychotherapist in the position of an expert. Naturally, a therapist does not “take control,” decide on a client’s goals, or direct a client what to do. Ultimately, it is the client who has to take matters into his or her own hands by thinking or acting differently. Formulation has to be a collaborative activity. Some forms of therapy do not pretend to offer an expert analysis derived from a therapist’s stock of knowledge and I discuss these “non-expert” styles in Chapter 6. I will now give a general outline of case formulation and the tasks in which it is embedded.

Case Formulation in Context

On first acquaintance with a new client, a therapist is bound to wonder “Why has this person come?” “Why has she come right now?” “What is the real nature of the problem?” and “Am I able to offer what this client is looking for?” These questions begin to be answered when a therapist has constructed a case formulation. There is no widely accepted definition of a case formulation but most authors would include the following elements: a descriptive summary of the main problems broken down into their constituent components and situational triggers; how the components relate to one another, informed by a therapist’s conceptual framework; an understanding of how a problem developed and is currently maintained; and some indication of a plan for how a problem can be resolved, based on a considered rationale.

Formulation skills are held in high regard in all forms of psychotherapy. This esteem acknowledges the complexity of problems and the contribution that a good formulation can make to the success of therapy. Therapists believe it to be unethical to intervene without a rationale for what they are trying to achieve—it gives a therapist confidence that she or he can respond appropriately. Although an initial formulation is usually revised later on, there is a brief initial stage in which a therapist is under pressure to decide whether he or she feels competent to deal with a problem or whether a client should be referred on for a different kind of service.

What happens in these first few sessions when problems are formulated is likely to be critical for later success. Although in recent years there has been a marked increase in the number of books published on case formulation, there is still a wide gap between the esteem in which it is held and the availability of a hands-on description of what it entails. When therapy does not go smoothly, a therapist is advised to make a careful and comprehensive appraisal of all the factors that could account for the difficulty. But there are rather few accounts of the process to which a therapist can turn. This may explain why novices are advised (and usually required) to seek out regular supervision from someone “more experienced.” However, experience does not always count—it is easy enough to fail to appreciate the significance of an aspect of a client’s situation or simply to get things wrong. It is for this reason that highly experienced therapists still seek out peer supervision. What ought to be of help here is a “method”—a systematic way of carefully reflecting on the circumstances surrounding a problem.

It is possible, but rather unlikely, that therapeutic success depends on accidental factors, such as a happy match between the personalities of therapist and client, or events occurring, as if by chance, in a client’s life. These may be important contributors to outcome but evidence of consistent differences in the success rates of different therapists (see below) points to therapeutic skill. I will assume that at least one component of being a therapist who achieves good results is a skill in case formulation. This skill may not be sufficient by itself but its importance can hardly be denied. My aim is to present a method for structuring the process of formulation within a functional framework that is intended to be compatible with a wide range of conceptual models. It is clearly unsatisfactory to leave the ability to formulate in the position of an occult craft, and what follows is a step toward making it transparent.

The chief justification for good case formulation is pragmatic—that the analysis of a problem assists both therapist and client to work effectively toward its solution. Formulation, as noted, is a collaborative activity. There has to be a sharing of perspectives on what the problem is and how to approach it, otherwise therapy would never get started. The process involves a gradual, mutual shaping of an understanding, which, at some point, calls for decisions to be taken about what to do. If a therapist lays claim to expertise, she or he might have to argue a case that a certain course of action (based on her or his own understanding) is advisable. In this sense, the process can be gently adversarial as well as collaborative. There seem to be few arguments in favor of pursuing an intervention simply because a client wants it. In any case, practitioners are unlikely to be effective when they do not believe in what they are doing.

A major portion of the work of case formulation takes place at the start of therapy and sometimes in just one session. In this initial phase there are many other tasks to perform, such as getting acquainted with a client, informing him or her of what to expect, explaining the ground rules of the relationship, and providing information about the rationale of therapy. However, in order to limit the length of this book, I do not make these tasks, or the formation of a therapeutic relationship, a central theme. Aspects of the relationship will be discussed along the way but I will be concerned primarily with a therapist’s conceptual understanding of a problem. This understanding typically develops within an interview assessment, supplemented by various additional means of gathering information (see Guidelines). The end result is a kind of negotiated account of the problem that satisfies both parties. However, this account should always be seen as open to revision or renegotiation. The chosen title of this book, individual case formulation, is intended to indicate that the process is not one of matching a client to a preconceived model of a problem. The title emphasizes the fact that no one client is identical to another and that a therapist, even when following a standard protocol, has to adjust an intervention to a client’s unique circumstances. Of course, a client’s problem is never entirely unique and it has to be understood within a framework of prior knowledge of effective techniques, psychological theory, and a familiarity with cultural norms and practices.

The first phase of therapy is generally known as “assessment and formulation” and something needs to be said about its defining limits. Given that the process of gathering information never really stops at any point, reformulation is the rule rather than the exception. A client may conceal crucial facts about him- or herself (not necessarily deliberately) and only reveal them six months or more into therapy. In practice, the first stage ends when a therapist feels that he or she has enough information to be going on with in order to initiate an intervention that it is believed will make a difference. If this stage is not reached, it seems best not to proceed at all, as then it would simply amount to groping around in the dark. Preliminary discussion is sometimes sufficient by itself, if only to conclude that there is nothing to be done. One criterion for proceeding is that the client has been sufficiently “educated” into the rationale of the methods employed. Reading matter, such as information leaflets or chapters from a self-help book, is often a valuable means of educating a client into the type of therapy on offer (see Guidelines).

In all styles of therapy, whether prescriptive or open-ended, a case formulation helps to match a set of interventions to the unique constellation of circumstances of a client’s life. Foremost are a client’s long-term and short-term objectives, the feasibility of achieving them given inevitable social constraints, the residue of historical habits that impede change, and the current factors that seem to be perpetuating a problem. Even in non-directive forms of therapy, some discipline has to be exerted over the way a client’s problems are understood. The approach to formulation that I set out in the Guidelines will assume that a therapist possesses basic interviewing and counseling skills. My presentation of case formulation as a process is largely concerned with strategies for obtaining relevant information, organizing it, and submitting it to interpretation and evaluation. The approach could be described as a set of rules of sorts. However, it is not a manual that is rigidly prescriptive.

If the need for an individual formulation sounds convincing, why has so little been written about the process and why have researchers come to the conclusion that it does not really matter too much what kind of psychotherapy is offered (Wampold, 2010)? Although it is widely agreed that psychotherapy is effective, it has been much harder to demonstrate differences in outcome between different approaches to the same problem (e.g. Elkin et al., 1989; Shapiro et al., 1994). The finding of equivalent results with very different methods is a challenge to the intuition that an accurate formulation, identifying key obstacles to problem resolution, is an important determinant of success. There are common helpful elements in all types of psychotherapy, and perhaps it is these that are critical for success rather than a good analysis of the presenting problem. Another possibility is that therapists who adopt different theoretical models come up with similar useful interventions in practice. Some researchers have argued that the accuracy of a formulation may not matter as long as it is convincing and leads to changes that a client finds beneficial. Other factors to consider when accounting for equivalent results are methodological. Problems are often evaluated in a gross and standard manner rather than in terms of specific difficulties that are, or would be, responsive to a tailored intervention. In any case, given that a well-founded formulation is only one possible determinant of success, it would not be too surprising if a fog of other influential factors were to obscure its role. Whatever the eventual explanation for the finding of equivalent results with different types of therapy (and this is by no means a uniform finding), I assume that it will not diminish the important role of case formulation.

Different Models of Case Formulation

There are marked differences in the way case formulation is undertaken in different forms of therapy. Some of them can be attributed to the enormous variety of clients that come to therapy. A client could be someone living in an institution, a child and his or her family, a couple, or a person with a health problem. I have restricted the scope of this book to adults who are living independently and, for the most part, are seeking one-to-one therapy over a relatively brief period of time. However, the proposed guidelines for assessing and formulating problems need not be seen as limited to this client group, or to one-to-one therapy alone. I have attempted to produce a method that can be generalized.

I have taken the interview to be the chief means through which information about clients’ difficulties is collected because this reflects everyday practice. Standardized assessments may be performed as well but these cannot individualize a problem to a sufficient degree or relate it to the overall context of a client’s life. Much of the information that is gleaned (and inferred) lies outside the strict content of what is said. The interview, combined with additional sources of information, enables a therapist to amass what might be called “facts” or “observations” from which inferences can be drawn. Through a process of reasoning, a therapist generates a number of “hypotheses” to explain these “facts” and how they relate to the origins of a problem and its persistence. I will take it that the making and interpretation of observations is a process common to all forms of therapy. The terms “observation” and “hypothesis” are not meant in an overly technical or scientific sense. I use the term hypothesis to include speculation, conjecture, hunch, and inference. The distinction between observation and hypothesis is a useful one, even though it may not be easy to justify philosophically. It has the advantage of making it possible to talk about a process of formulation that can be seen as applicable to all types of therapy. It is assumed that problems have causes and that it is possible to understand them theoretically. I develop this model of practice in Chapters 4 and 5.

As already noted, there is no uniform approach to case formulation. With so little research having been undertaken into formulation as a process, it is difficult to interpret the significance of the differences that exist. If we knew better what therapists actually do when formulating, we would probably make more progress toward a genuine integration across therapies, rather than settling for a pragmatic eclecticism. A significant aspect of all therapeutic activity is the role it plays in the life of a culture (Rose, 1998). It is possible that a better understanding of individual problems, and how they can be formulated in different ways, would suggest policy changes at a societal and political level (Rosenwald, 1988). Some light could be thrown on this if...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Preface
• Acknowledgments
• Chapter 1. Formulation—the Main Issues
• Chapter 2. Conceptual Frameworks for Case Formulation
• Chapter 3. Evidence-Based Practice: Diagnostic and Transdiagnostic Approaches
• Chapter 4. Theory and Evidence in Individual Case Formulation
• Chapter 5. The Process of Reasoning in Individual Case Formulation
• Chapter 6. Narrative and Textual Analysis in Formulation
• Chapter 7. Formulation Skills and the Therapeutic Relationship
• Chapter 8. A Functional/Systemic Framework for Case Formulation
• Chapter 9. Future Prospects for Individual Case Formulation
• Appendix. Guidelines for Assessment and Constructing an Individual Case Formulation (ICF)
• Bibliography
• Index